The Overlap of ADHD and ASD: Clinical Presentation and...
Transcript of The Overlap of ADHD and ASD: Clinical Presentation and...
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The Overlap of ADHD and ASD:
Clinical Presentation and Treatment
The 14th Annual NADD: State of Ohio Conference
Ernest Pedapati, MD, MS, FAAP
Assistant Professor
Division of Psychiatry and Neurology
Disclosure: Ernest Pedapati, MD
Research Support
Cincinnati Children’s Research Foundation
American Academy of Child and Adolescent Psychiatry
Stock/Equity (any amount) None
Consulting / Employment None
Speakers Bureau / Honoraria None
Other None
My Role at Cincinnati Children’s
Child Psychiatrist for Developmental Disabilities
Principal Investigator – Autism Research Group
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Conclusions
1. ADHD in children with Autism represents a clinical
population with unique challenges
2. ADHD can overlaps ASD symptoms amplifying
deficits in executive function and social
communication.
3. Successful diagnosis and treatment is a careful
“dance” of monitoring and intervention.
Objectives
1. Characteristics of autism spectrum disorder (ASD)
2. Characteristics of ADHD in ASD
3. Evaluation of co-occurrence of ADHD in ASD
4. Untangling ADHD and ASD symptoms
5. Evidence-based treatment options
University of Colorado
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NIST-F2 Atomic Clock
Neurodiversity
Human Brain (DTI)
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An abstraction of mind which made him perfectly oblivious to everything about him. He appears to be always thinking and thinking, and to get his attention almost requires one to break down a mental barrier between his inner consciousness and the outside world.
Leo Kanner, MD
Autistic Disturbances of Affective Contact , 1943
A description of “Tim”
IDEA Definition of ASD
Under the Individuals with Disabilities Educational Act,
Autism is a developmental disability significantly
affecting verbal and nonverbal communication and
social interaction, usually evident before age 3 that
adversely affects a child’s educational performance.
Other characteristics often associated with ASD are
engagement in repetitive activities and stereotyped
movements, resistance to environmental change or
change in daily routines, and unusual responses to
sensory experiences.
Clinical Features of Autism
Reciprocal Attention Joint Attention
Sensory Overload
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Clinical Features of Autism
Non-communicative
Gestures
Preoccupation with
Parts
TRAJECTORIES OF ASD
The Many Faces of Autism
Case A: “Tommy” Case B: “Mary”
Non-verbal
Group home
Day programming
Intellectual disability
Meets full DSM criteria
Fluent
Lives independently
Software programmer
High IQ
Meets full DSM criteria
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DSM-5 combines impairments in
communication with social interactions
DSM-IV TR DSM-5
Required 3 Deficits
• Social interactions
• Communication
• Restrictive, Repetitive
and Stereotyped
Behaviors
Required 2 Deficits
• Social communication
and interactions
• Restrictive &
Repetitive Behaviors,
Interests, Activities
Autism Spectrum Disorder
Outdated but still useful!
Definition of Autism is Changing
DSM
ICD
IDEA
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Social deficits
Intellectual Disability
Speech/communication
deficits
Expressive/Receptive
Language Disorders
Social
Anxiety
Aggression
Self-Injury
Restrictive Interests
And Repetitive behaviors
The Unique Fingerprint of Autism
Known
Genetic Defect
Autism by the Numbers
Male : Female Ratio 4:1
Girls in general are more severely affected.
> 40% without intellectual disability
No association between race, immigrant
status, or social class and autism
20-30% with a seizure disorder
Fombonne 2007; CDC 2013
Autism by the Numbers
CDC currently estimates that 1 in 50
individuals have ASD (2013) CDC 2013
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Controversy: Is ASD
increasing?
The changes in the definition of Autism
more sophisticated diagnostic methods
Better at identifying whole “spectrum”
More aware of condition
Implications for service (“diagnostic substitution”)
Likely “real” increase in incidence
Probably a combination of both
How does
Autism
develop?
Genetic & Environmental
Factors
Changes in Brain
Development
Changes in Brain
Function
Changes in Cognition
Changes in
Behavior
How does
Autism
develop?
Genetic & Environmental
Factors
Changes in Brain
Development
Changes in Brain
Function
Changes in Cognition
Changes in
Behavior
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High rate of concordance for autism and related symptoms in MZ and DZ twins. 2-10% of siblings have autism Fraternal Twins have a 20 to 30% chance of dual diagnosis One of the most heritable diseases Larger role for environmental factors in current studies
Genetics of Autism
De Rubeis, S., & Buxbaum, J. D.
(2015). Genetics and genomics of
autism spectrum disorder:
embracing complexity. Hum Mol
Genet.
Where in the
brain is
ASD?
Genetic & Environmental
Factors
Changes in Brain
Development
Changes in Brain
Function
Changes in Cognition
Changes in
Behavior
Summary of Brain Changes in ASD
Larger head (16%) and brain (9%) sizes
Difference is prominent in early childhood
(when symptoms start)
Head size normal at birth
Meta-analysis (Sacco 2015)
Many regions of the brain are involved (Chen
2015)
Specific genes have been identified that have
to do with brain development and function
(Geschwin 2011)
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BASAL
GANGLI
A
http://destroma.deviantart.com/
CEREBRAL
CORTEX
HIGHER FUNCTIONS
MOVEMENT
PERCEPTION
REACTIONS
CORPUS
CALLOSUM
BASAL
GANGLI
A
http://destroma.deviantart.com/
AMGYDALA AND
HIPPOCAMPUS
EMOTIONS
MEMORY
BASAL
GANGLI
A
http://destroma.deviantart.com/
BASAL GANGLIA
AUTOMATIC
MOVEMENTS
BALANCE
COORDINATION
CEREBELLUM
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Gogtay 2004
Brain Development Over Time
Convergence of genes on neural systems
Figure from Geschwind 2011
Behavorial Implications of
Developmental Changes in ASD
Socialization Communication
Restrictive Interests
Repetitive Behaviors
Sensory Abnormalities
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Common ASD Challenges
Difficulties with communication
Pragmatic and figurative
Difficulties with change and transition
Preference for familiar and routine
Difficulties with behavior
Emotional regulation
Difficulties with sensory issues
Sounds, lights, textures, and tastes
Don’t diagnosis ADHD in children with ASD
(pre-DSM-5)
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Objectives
1. Characteristics of autism spectrum disorder (ASD)
2. Characteristics of ADHD in ASD
3. Evaluation of co-occurrence of ADHD in ASD
4. Untangling ADHD and ASD symptoms
5. Evidence-based treatment options
Obvious now, but longstanding error!
Decades of research argued for and
supported the dual ASD/ADHD diagnosis
(Lietner 2014)
Co-occurrence of ADHD and ASD is
associated with a lower quality of life and
poorer adaptive functioning than in any one of
these conditions (Vora and Sikora, 2011)
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Dr. Heinrich Hoffman 1843
“Fidgety Phil”
Let me see if Philip be a little gentleman; Let me see if he is able to sit still for once at table”
But fidgety Phil, he won’t sit still; He wriggles and giggles and then, I declare, swings backwards and forwards, and tilts up his chair,
See the naughty, restless growing still more rude and wild, till his chair falls over quite. Philip screams with all his might, catches at the cloth, but then that makes matters worse again.
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Similarities: ASD and ADHD
ADHD overlap ASD Source
Neuropsychology Profiles Gargaro 2011 Rommelse 2011
Pragmatic Language Bishop 2001
Emotional Regulation Buitelaar 1999
Theory of Mind Buiterlaar 1999, Marton 2009
Key Points of ADHD in ASD
Hyperactivity, impulsivity, and inattention are
key “ADHD symptoms”
Evaluation can be difficult due to overlap with
features of individuals with ASD
Psychotropic ADHD medication may not be
as effective in ASD
Limited access to specialty referral.
(Mahajan 2012 Pediatrics)
ADHD symptoms in Autism
Seeking help with ADHD symptoms (Gadow 2006, Ousley 2006)
37 to 85%
ASD Preschoolers with hyperactivity (Carlsson 2013)
33%
5-17 y.o. met full criteria for ADHD (Leyfer 2006)
31%
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Objectives
1. Characteristics of autism spectrum disorder (ASD)
2. Characteristics of ADHD in ASD
3. Evaluation of co-occurrence of ADHD in ASD
4. Untangling ADHD and ASD symptoms
5. Evidence-based treatment options
Clinical Practice Pathways for Evaluation and Medication Choice for
ADHD Symptoms in Autism (Mahajan)
Medication choice subcommittee developed a
practice parameters (2012)
Critical review of 31 articles
Establish ASD diagnosis including language
and cognitive testing
Core ASD symptoms
Optimize educational, speech and language,
and behavioral supports
Systematic medical evaluation for any
undiagnosed conditions (i.e. seizures)
Autism Speaks Autism Treatment Network
Psychopharmacology Committee
Child with ASD referred for ADHD
symptoms
Does child have significant ADHD symptoms per
teachers/parents?
Do medical or sleep problems
contribute to the symptoms?
Anxiety or mood disorders?
Discrepancy between settings?
Behavioral support
Medication trial (Mahajan 2012 Pediatrics)
ADHD symptoms in Autism
evaluation practice pathway
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Child with ASD referred for ADHD
symptoms
Does child have significant ADHD symptoms per
teachers/parents?
Do medical or sleep problems
contribute to the symptoms?
Anxiety or mood disorders?
Discrepancy between settings?
Behavioral support
Medication trial (Mahajan 2012 Pediatrics)
ADHD symptoms in Autism
evaluation practice pathway
Challenge #1
Challenge #3
Challenge #2
Objectives
1. Characteristics of autism spectrum disorder (ASD)
2. Characteristics of ADHD in ASD
3. Evaluation of co-occurrence of ADHD in ASD
4. Untangling ADHD and ASD symptoms
5. Evidence-based treatment options
ADHD versus ASD Symptoms
Core ADHD Features
Triad of
attentional difficulties
over activity
impulsive behaviors
May be ASD features
Hyperactivity
Stereotypy, anxiety,
medications
Inattention
Social situation and/or
simple non-preferred
activities
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How would a parent of a child with ADHD or ASD
interpret these questions differently?
Vanderbilt Form
Challenge #1:
Executive Function (EF) Overlap
EF AUTISM ADHD
Executive Function
Executive Function is the ability to
maintain problem solving skills to
guide future behaviors (Welsh and
Pennington 1988)
Impairments in executive function
lead to difficulties in developing
independence.
Executive function deficits in ASD
are varied and pervasive and
distinct (Hovek 2014; Pugliese
2014)
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Overview of Executive Function
Initiation • i.e. social interaction
Monitoring • Attention to environment
Evaluating • Different expectations
Executive Function: Initiation
Difficulty with starting a behavior such as
homework, a chore, or social interaction.
Internal Reasons
Planning difficulties (i.e. motor system)
Processing speed
External Reasons
Attention to Environmental Stimuli
Differing motivations (positive reinforcements)
Unclear expectations and uncertainty
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Missing Information
Loss of critical
information in verbal
and non-verbal
communication
Reduced initiation of
social learning
opportunities
Decreased requests for
assistance
(Mundy & Stella 2000)
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Executive Function:
Generalization
Cognitive flexibility is a particular deficit in
ASD (Solomon 2007; Hill 2004)
Principal
Example
Example
Example
That assignment was hard.
All assignments are hard.
I always do this at home.
I will do this at school too.
Executive Function:
Generalization
Have difficulty shifting to a
new or different thought or
action in a different
environment
A very unique school
setting (i.e. classroom,
staff, and activities) can
further limit generalization
(Horner 1989)
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Executive Function:
Generalization
Extreme difficulty relating new stimuli to past
experiences
Slight environmental changes
New personal
New activities, even if slightly different
May not recognize situation if slightly altered,
i.e. one dimensions is a novel stimulus
Additional instruction needed for
independence
Can you spot the difference?
Can you spot the difference?
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Prompt Dependence
Overreliance or dependence on adult support
may inhibit independence
Great for initially learning a skill quickly
Common teaching strategies including
prompts for initiating work and rewards for
completion (Smith 2001)
Students with primary 1 on 1 instruction at risk
Allowing students to practice without
interruption may lead to more generalized
success (Binder 1993)
Summary of Challenge #1
The core deficits of ASD can be identified in
the classroom
Other less commonly discussed symptoms,
such as executive function deficits can
explain dysfunctional classroom behavior
Encourage assessment for more relevant
intervention ("one size does not fit all")
Evidence-based intervention are available but
you must stay up to date
Does child have significant ADHD symptoms per
teachers/parents?
Yes, ASD interventions have helped
No, ASD interventions did
not help
Child with ASD referred for ADHD
symptoms
Does child have significant ADHD symptoms per
teachers/parents?
Do medical or sleep problems
contribute to the symptoms?
Anxiety or irritability disorders?
Discrepancy between settings?
Behavioral support
Medication trial (Mahajan 2012 Pediatrics)
ADHD symptoms in Autism
evaluation practice pathway
Challenge #1
Challenge #3
Challenge #2
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Dual Diagnosis:
Mental Health in Autism
Syndromic
Presentations
Decreased
Reserve
Atypical
Response
Atypical
presentation
Tend to be more common in higher functioning persons
Common triggers:
Issues with self-esteem
Coping with an understanding of deficits associated with ASDs
Academic issues
Potential to be bullied
Decreased social and emotional insight, motivation/desire to have friends
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Development of Mood & Anxiety
Disorders in the Context of DD
Aggression, Self-Injury, and
Irritability is Common in ASD
Up to 30% of children with autism may have
irritability
aggression (25%)
severe tantrums (30%)
deliberate self-injurious behavior (16%).
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Aggression and Self-Injury
What does irritability in children with Autism look like (Table 1)?
o Injures self on purpose o Cries over minor annoyances o Aggressive towards others o Mood change quickly o Screams inappropriately o Cries and screams inappropriately o Temper tantrum/outbursts o Stamps feet while banging objects o Irritable and whiny o Deliberately hurts himself/herself o Yells at inappropriate times o Does physical violence to self o Depressed mood o Has outbursts when does not get their own way o Demands must be met immediately
Aberrant Behavior Checklist 1985
Common Irritability and Mood
Presentations
Persistant Impulsive Explosive Anxious
Each category has different associated diagnoses
and treatment options
Common Irritability and Mood
Presentations
Persistant Impulsive Explosive Anxious
Irritability
DBD
Mood disorders
Medical (GI)
ADHD
ID & LD
Motor
IED
ASD & PTSD
ID
OCD
Anxiety
Trait
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Summary of Challenge #2
Anxiety or
irritability
disorders?
Yes, consider co-morbidity treatment
No, consider ADHD treatment
Objectives
1. Characteristics of autism spectrum disorder (ASD)
2. Characteristics of ADHD in ASD
3. Evaluation of co-occurrence of ADHD in ASD
4. Untangling ADHD and ASD symptoms
5. Evidence-based treatment options
Child with ASD referred for ADHD
symptoms
Does child have significant ADHD symptoms per
teachers/parents?
Do medical or sleep problems
contribute to the symptoms?
Anxiety or mood disorders?
Discrepancy between settings?
Behavioral support
Medication trial
(Mahajan 2012 Pediatrics)
ADHD symptoms in Autism
evaluation practice pathway
Challenge #1
Challenge #3
Challenge #2
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Medications Use is Rising in
Youth with ASD
65% of youth with ASD are treated with at
least one psychotrophic medication
35% have evidence of 1 or more medications
2 drugs have FDA approval labeling for use in
autism
Rosenberg et al., 2010; Schubart, Camacho, & Leslie, 2014; Spencer
et al., 2013
Limited vocalizations
Can be aggressive and difficult to redirect.
Easily frustrated
Self-contained classroom
Case 1: 14 y.o. male ASD “Irritable”
Initial History
There are only so many ways to
describe behavior for clinicians and
families!
Limited vocalizations
Unable to sit for speech therapy
Can be aggressive and difficult to redirect
Goofy, almost inadvertent aggression
Otherwise happy
Easily frustrated
Difficulty attending to even 5 minute tasks
Self-contained classroom
Was unable to attend to lessons
Case 1: 14 y.o. male ASD “Irritable”
Targeted Classification
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Common Irritability and Mood
Presentations
Persistant Impulsive Explosive Anxious
Irritability
DBD
Mood disorders
Medical (GI)
ADHD
ID & LD
Motor
IED
ASD & PTSD
ID
OCD
Anxiety
Trait
Case 1: 14 y.o. male ASD “Irritable”
Outcome
After discussion with parents with started
methylphenidate 20 mg twice a day
First weekend
Current progress
Evidence for Stimulant Use
Methylphenidate
Ritalin, Metadate, Concerta, Focalin, Daytrana patch
Amphetamines
Adderall, Dexedrine, Vyvanse
Increases concentrations of dopamine and
norepinephrine in the pre-frontal
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Stimulants: Evidence of Effect
RUPP Trial of Methylphenidate (2005) Design:
Double-blind, placebo-controlled crossover trial
1 week each of placebo, low, medium, and high dose MPH in random order
Primary outcome of interest: Reduction of Hyperactivity subscale score on ABC (Aberrant
Behavior Checklist)
Sample: 72 children with ASD ages 5 to 14 years
Autistic Disorder (71%), PDD-NOS (21%), Asperger (7%)
Mean IQ of 63 (range 16-135)
Stimulants: Evidence of Effect
RUPP trial of Methylphenidate (2005)
Results
ABC Hyperactivity improved
49% were “responders” to MPH vs. 13% to placebo
Adverse effects in 18% of subjects: Irritability,
decreased appetite, difficulty falling asleep,
emotional outbursts
Stimulant Response in ASD
MR
54% response (Aman 1996)
ASD
49% response (RUPP 2005)
ADHD
Kids 70%/90% (Wigal 2012)
ADHD
Adults MPH 76% (Spencer 2004)
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Other ADHD Medications
Alpha-2 agonists (guanfacine
(Tenex) or clonidine)
Atomoxetine
Atypical antipsychotics
(risperidone, etc.)
Summary of Challenge #2
ADHD
Medication
Trial
Identified effective treatment
Stimulants
Atomoxetine
Alpha-2
High functioning with intact language
Mostly difficult with sustained attention
classes
Previous stimulant trials had resulted in
severe irritability and mood swings
Case 2: 17 y.o. female ASD “impulsive”
Initial History
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Case 2: 17 y.o. female ASD “inattentive”
Targeted Classification
High functioning with intact language
Reviewed cognitive testing showing
decreased processing speed
Above average IQ
Mostly difficult with sustained attention
classes
Reading, homework, organization
Previous stimulant trials had resulted in
severe irritability and mood swings
Patient described feeling very uncomfortable,
but focus was improved
Common Irritability and Mood
Presentations
Persistant Impulsive Explosive Anxious
Irritability
DBD
Mood disorders
Medical (GI)
ADHD
ID & LD
Motor
IED
ASD & PTSD
ID
OCD
Anxiety
Trait
Case 2: 17 y.o. female ASD “inattentive”
Outcome
Restarted low-dose stimulant with atypical
antipsychotic
Needed titration of both medications for
improvement
Irritability was mitigated by atypical
antipsychotics in the RUPP MPH trial.
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Independence in ASD
What features of ASD contribute to difficulties
in independence?
Social and communication deficits
Restricted, repetitive, stereotypic behaviors
Joint attention and imitation
Limited social interest
If ADHD comorbidity is an impediment to
learning, the risk of not treating is potentially
years of sub-optimal learning.
Improvement Model
Assessment
Response
Revise and Modify
Conclusions
What features of ASD contribute to difficulties
in independence?
Social and communication deficits
Restricted, repetitive, stereotypic behaviors
Joint attention and imitation
Limited social interest
If ADHD comorbidity is an impediment to
learning, the risk of not treating is potentially
years of sub-optimal learning.
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Conclusions
1. ADHD is a common and impairing co-morbidity in
ASD
2. There are systematic ways of assessing for ADHD
in ASD
3. Untangling ADHD and ASD symptoms can be
complicated and requires knowledge/experience of
both disorders
4. Effective evidence based treatment options are
available.
Summary and Goal of Treatment
Increase in Learning Individual Burden
Increase Well-being Caregiver Burden
Increase Independence Societal Burden
If ADHD comorbidity is an impediment to
learning, the risk of not treating is
potentially years of sub-optimal learning.
Thank you
Special Thanks to
Craig Erickson and Logan Wink (Psychiatry)
Patty Manning and Susan Wiley (DDBP)
Sergio Delgado (Psychiatry)
Donald Gilbert and Steve Wu (Neurology)